INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 21, 2026, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Mainstream Counseling, Inc. was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
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Plan of Correction
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709.28 (c) (2) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included the specific information disclosed in one out of seven records reviewed.Client #4 was admitted on June 20, 2025, and discharged on February 24, 2026. The record contained one informed and voluntary consent to release information to a funder signed by the client on May 21, 2025, that did not document the specific information to be released. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
- At the conclusion of the inspection, clarification was sought and received from DDAP Licensing Specialist regarding release authorizations and the section pertaining to the specific information to be released.
- Initial review of inspection findings in post-inspection Administration meeting on 4/21/2026.
- On 4/28/2026, the Clinical Supervisors and Director met to identify documentation, and staff education needs to ensure compliance with standards for completion of release authorization forms.
- During Group Supervision on 5/12/2026, all Clinical staff were educated on the need to complete all sections of the consent in full, to include properly identifying the specific information to be disclosed.
- A Clinical documentation workshop will be scheduled for early Summer 2026, during which time will be spent reviewing all components of a release authorization.
- Monitoring for compliance will continue monthly through the following means:
1) Clinical Supervisor for QI (with help of support staff) will complete an audit of three (3) randomly selected open files from each counselor to identify deficiencies and ensure compliance. The Director will randomly audit two (2) of the Clinical Supervisor's files. A standard rubric for chart review will be utilized and returned to individual counselors with the files to ensure correction of identified deficiencies.
2) Clinical Supervisor and Director will meet monthly to review chart audit results, identify individual staff re-education needs and develop a staff retraining plan, if indicated.
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709.28 (c) (3) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(3) Purpose of disclosure.
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included the purpose of disclosure in one out of seven records reviewed.Client #4 was admitted on June 20, 2025, and discharged on February 24, 2026. The record contained one informed and voluntary consent to release information to a funder signed by the client on May 21, 2025, that did not document the purpose of the disclosure. This is a repeat citation from the April 1, 2025, licensing inspection. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
- At the conclusion of the inspection, clarification was sought and received from DDAP Licensing Specialist regarding release authorizations and the section pertaining to the purpose of the disclosure.
- Initial review of inspection findings in post-inspection Administration meeting on 4/21/2026.
- On 4/28/2026, the Clinical Supervisors and Director met to identify documentation, and staff education needs to ensure compliance with standards for completion of release authorization forms.
- During Group Supervision on 5/12/2026, all Clinical staff were educated on the need to complete all sections of the consent in full, to include properly identifying the purpose of the disclosure.
- A Clinical documentation workshop will be scheduled for early Summer 2026, during which time will be spent reviewing all components of a release authorization.
- Monitoring for compliance will continue monthly through the following means:
1) Clinical Supervisor for QI (with help of support staff) will complete an audit of three (3) randomly selected open files from each counselor to identify deficiencies and ensure compliance. The Director will randomly audit two (2) of the Clinical Supervisor's files. A standard rubric for chart review will be utilized and returned to individual counselors with the files to ensure correction of identified deficiencies.
2) Clinical Supervisor and Director will meet monthly to review chart audit results, identify individual staff re-education needs and develop a staff retraining plan, if indicated.
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